Patients caught in the middle

LEWISTON — With a mid-January deadline fast approaching, executives at Regence BlueShield of Idaho and St. Joseph Regional Medical Center in Lewiston have yet to reach an accord.

Both sides have indicated they continue to negotiate to keep the hospital in the insurance provider’s network.

At issue is how much St. Joe’s charges Regence for the medical care Regence customers receive at the hospital or from its employees, which include a number of physicians, nurse practitioners and physician assistants.

Those differences remain. A letter Regence sent to its customers in St. Joe’s service territory stated the hospital plans to leave the Regence network shortly after the start of the new year.

“Despite our best efforts to reach an agreement on a fair, updated contract, St. Joseph’s Tennessee-based owner, LifePoint Health, is choosing to remove the hospital from the Regence network Jan. 16, 2020,” according to the letter.

If the two sides can’t find a compromise, the impact would be far-reaching for the more than 15,000 people Regence insures in the area, for St. Joe’s and for other medical institutions in the region.

Question: How much would it cost Regence subscribers if they continued to use St. Joe’s when it wasn’t a part of the Regence network?

Answer: It depends. Almost all nonemergency services that Regence customers receive at St. Joe’s or from medical professionals employed by the hospital in its clinics would be billed as out-of-network care. That would include office visits, tests and surgeries. Typically Regence reimburses at higher percentages for in-network care than out-of-network care, said Lou Riepl, a spokesman for Regence.

Care for emergencies such as heart attacks, strokes, severe automobile accidents, gunshot wounds and roof-top falls would be billed in-network, Riepl said.

The insurance provider has instructed those being treated for cancer and women who have babies due within a week or two of the January deadline to contact the insurance provider “so we can help plan your continued care,” according to the letter.

The other significant variable is the approach that St. Joe’s will take, and St. Joe’s isn’t disclosing how it would handle the change.

The hospital could choose to “balance bill” Regence customers for any care they receive at St. Joe’s whether or not Regence defined it as in network or out of network, Riepl said.

Here is an example. Say a surgery costs the hospital $25,000 and Regence has determined its allowed cost for that procedure is $20,000. Regence would base its reimbursements to its customer based on $20,000 whether the procedure was considered in network or out of network. The hospital could bill the Regence patient the remaining $5,000, which would not be offset by any Regence payment.

A spokeswoman for St. Joe’s provided this response when asked if the hospital plans to balance bill:

“Patients pay Regence good money each month with the expectation that they will have access to the physicians and nurses they know and trust,” said Samantha “Sam” Skinner in an email. “It is Regence’s responsibility to ensure its members have access to the care they need, and it’s (St. Joe’s) responsibility to care for patients. The physicians, nurses and other caregivers at (St. Joe’s) will always provide care to any patient who walks through our doors — regardless of the patient’s insurance.”

Q: St. Joe’s has the highest trauma care rating of any hospital in north central Idaho and southeastern Washington. What hospitals in the Spokane and Coeur d’Alene area have the same trauma care rating or higher and will continue to be in Regence’s network?

A: Providence Holy Family and MultiCare Deaconess. Both are in Spokane. More advanced trauma care is available from Providence Sacred Heart Medical Center and Children’s Hospital in Spokane and Kootenai Health in Coeur d’Alene.

Q: St. Joe’s is the only hospital that delivers babies in the Lewiston-Clarkston Valley. What other hospitals have that service in the area and are in Regence’s network?

A: Pullman Regional Hospital; Gritman Medical Center in Moscow; Clearwater Valley Hospital and Clinics, in Orofino; Whitman Hospital and Medical Center in Colfax; Syringa Hospital & Clinics in Grangeville and St. Mary’s Hospital in Cottonwood.

Q: St. Joe’s is the only hospital that offers chemotherapy and radiation in the Lewiston-Clarkston Valley. Where are the next nearest places for that care in Regence’s network?

A: Palouse Oncology & Hematology opened this year in Moscow. It has one oncologist and offers chemotherapy. The clinic is a collaboration of the hospitals in Moscow, Pullman and Colfax and Cancer Care Northwest. Radiation therapy is available at Cancer Care Northwest in Spokane and Coeur d’Alene.

Q: What options are there for general care such as annual physicals that will continue to be in Regence’s network in the Lewiston-Clarkston Valley?

A: Physicians, nurse practitioners and physician assistants at Valley Medical Center in Lewiston, Lewiston Orthopedics and the providers at Tri-State Memorial Hospital in Clarkston, which owns Clearwater Medical in Lewiston, continue to be in Regence’s network. So do a number of independent practices such as Jennifer Kaufman ARNP, PLLC Liver and Digestive Diseases and Larsen Gastroenterology PLLC in Clarkston and Martin Family Medicine in Clarkston.

Q: Why don’t the employers who use Regence for medical insurance switch to another carrier?

A: It would possibly be a lot more expensive, said Mike MacDowell, an owner of Troy Insurance in Lewiston.

In many instances, Regence has significantly less expensive premiums, especially for employers with two to 50 employees, MacDowell said.

Q: What are the issues separating St. Joe’s and Regence?

A: The two sides haven’t shared exact numbers or other specifics about the talks.

“Regence pays below market average for the needed care (St. Joe’s) physicians and nurses provide,” Skinner said. “Fair contracts allow us to continue to have the resources needed to provide the high-quality care that our community currently receives at (St. Joe’s) and invest (in) the future health care that our community deserves.”

Regence has previously stated that, had it agreed to St. Joe’s terms, annual premiums would have increased by several hundred dollars to more than $1,000 per household.

Q: Why aren’t Idaho state regulators intervening?

A: There isn’t much they can do. The Idaho Department of Insurance approved Regence plans in September and will re-evaluate them again next year, said Dean Cameron, the director of the Idaho Department of Insurance in Boise in an email.

“Our regulatory authority is limited,” Cameron said. “(The Idaho Department of Insurance) regulates the carriers to make sure they have adequate networks in the market they are offering plans. … (The department) does not have the authority to force a contract between a carrier and a provider, although we (certainly) do encourage both sides to work together.”

Q: Until May of 2017, St. Joe’s was a not-for-profit. Since then it has been a private business that is a multibillion dollar investment firm, Apollo Global Management, that pays $2.5 million in taxes annually in the community. What role, if any, is that change in status playing in the negotiations?

A: Skinner said the hospital’s for-profit status is not a factor in this issue.

Cameron, the director of the Idaho Department of Insurance, disagrees.

“We are disappointed and frustrated in the situation,” Cameron said. “The difficulty is that the demands of the new ownership of the hospital are unrealistic and harmful to the cost of care in the Lewiston area.”

Elaine Williams may be contacted at ewilliam@lmtribune.com or (208) 848-2261.

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